Cross Cultural Care and Education in Geriatrics

1. Cross Cultural Care and Education in Geriatrics Jerry Johnson, M.D. Professor of Medicine University of Pennsylvania

2. Objectives • Overall Goal: Preparation to Teach Cross Cultural Aspects of Geriatrics • Anticipate predictable challenges • Relate your teaching content to the domains of cross cultural interactions • Apply mnemonics for interactions with patients and caregivers • Use diverse approaches to teaching • Identify resources for education and learning

3. Crossing the Quality Chasm • “The system by which health care is delivered and financed must be designed to ensure that care is safe, effective, efficient, equitable, timely, and tailored to each individual’s specific needs and circumstances.” - Institute of Medicine Report, 2001

4. Analytic Framework: Cultural Diversity Training for Providers Increase provider sensitivity to attitudes and beliefs which marginalize ethnic groups Decrease differential treatment due to unconscious discrimination Cultural diversity training programs for providers Improved health status outcomes Increase provider abilities and strategies for cross-cultural interactions Greater client adherence to care and treatment recommendations Decrease ethic differentials in utilization and treatment Increase provider knowledge of culturally-based beliefs and behaviors Increase use of culturally appropriate health care interventions Greater satisfaction with care

5. Challenges of Cross-cultural Care • Defining the concept of culture • Concern about stereotyping, relevance and legitimacy • Cross cultural care overlaps with other aspects of clinical care: professionalism, humanism • Multiple levels of cultural competence • the health professional- patient relationship • the health system • the community

6. What is Culture? • Acquired attitudes, values and beliefs or “unwritten rules of behavior.” • Caveats • Culture is not synonymous with race or ethnicity, but... • “Culture is not a fixed, knowable entity that guides individuals’ behaviors in linear ways” (see Gregg J. Losing Culture on the Way to Competence: the use and misuse of culture in medical education. Acad Med 2006: 81: 542-547). • Culture is mutable and multiple.

7. Cross cultural education is relevant because health care is delivered in a cultural context.

8. Relevant Cultural Constructs • The culture of the patient • The culture of the practitioner • The culture of the practitioner’s profession: e.g. medicine, nursing, and social work. • The culture of the workplace: health system, institution, or other entity

9. Relevance of Group Identities • Each individual’s identity is partly determined by group affiliation: gender, ethnicity, religion.... • Preservation of these group identities for many is a matter of self esteem • Group identity partly determines how others view us and interact with us Cox, Taylor . Cultural Diversity in Organizations. 1993

10. Content Areas or Domains of Cross- Cultural Care

11. Content Areas Relevant to Interactions • Self awareness • World view • Causation or explanatory models • Spirituality • Complementary alternative medicine • Help-seeking behavior (community and family) • Language and health literacy • Historical, social and economic factors CREATE SOME REPRESENTATIVE CASES

12. Case Example: Explanatory Model and Alternative Healing • Depression in a 75 yo man, self explained by the patient, and treated outside the formal health care system.

13. Case Example: Spirituality • Woman with multiple admissions for CHF accompanied by markedly elevated BP, who believes her faith, not medications, will treat HTN. • Woman dying of metastatic breast cancer who wants chemotherapy as an example of “being strong” and maintaining faith.

14. Case Example: Language issues • Russian speaking man admitted with pain and gait dysfunction

15. Case Example: social and economic factors • Woman with large family, inadequate funds, under significant stress

16. Negotiating with Patients and Families

17. Conceptual Framework • Emphasis on the illness and its context: • Kleinman’s questions: Eisenberg et al. Culture, illness, and care: clinical lessons from anthropologic and cross cultural research. 1978 • Carillo et al. Cross cultural primary care: a patient based approach. AnnalInt Med 130:829, 1999 • Explore the meaning of illness • Conduct a social context “review of systems” • Negotiate management

18. Kleinman’s Questions • 1 What caused it? • 2 Why now? • 3 How affects you? • 4 How severe is it? • 5 What treatment? • 6 What results expected? • 7 What chief problem? • 8 What do you fear most? • 9 What duration?

19. Mnemonics

20. Mnemonics for Cultural Interactions • LEARN • BELIEF • RESPECT • ETHNIC and ETHNICS • BATHE • ADHERE • Others

21. LEARN • Listen with sympathy and understanding to the patient’s perception of the problem • Explain your perceptions of the problem • Acknowledge and discuss the differences and similarities • Recommend treatment • Negotiate treatment Berlin E. Western Journal of Med 1983; 139: 934-938

22. BELIEF • Health Beliefs (What caused your illness ?) • Explanation (Why did it happen?) • Learn (Help me understand your belief/opinion) • Impact (How is this illness affecting your life?) • Empathy (This must be very difficult for you) • Feelings (How are you feeling?)

23. RESPECT • Respect: a demonstrable attitude • Explanatory model: patient explanation of cause • Social cultural context: gender, migration status, sexual orientation, economic group, history • Power differential: acknowledge it • Empathy: put into words • Concerns and fears: eliciting them • Therapeutic alliance and trust

24. ETHNIC and ETHNIC(S) • Explanation : What do you think is the reason for your sx? • Treatment: What kinds of treatment have you tried, what kinds of treatment do you want? • Healers: Advice from alternative healers? • Negotiate: discuss options and expected results • Intervention. Determine an intervention • Collaboration • Spirituality or Seniors Levin, S. Ethnic. Patient Care 2000; 34 (9): 188-189

25. BATHE • Background (what is going on in your life?) • Affect (How do you feel?) • Trouble (What troubles you most?) • Handling (coping) • Empathy (That must be very difficult)

26. ADHERE • Acknowledge (need for treatment and joint goals) • Discuss (potential treatments and alternatives) • Handle (questions) • Evaluate (health literacy and barriers to adherence) • Recommend (treatment) • Empower (the patient by listening)

27. General Tips in Cross Cultural Care • Avoid idioms • Use titles such as Mr. and Miss • Yes does not always mean yes • Be cautious of touching • Use trained interpreters when available

28. TRAINING TOOLS AND APPROACHES

29. Large Group Exercises • Aging Panel: Who are the elderly • Working with interpreters-film • Spirituality panel and case discussions • CAM presentation with practitioners

30. Small Group Activities • Discussion sessions following large groups, often with guests (seniors, chaplains) • Self awareness exercises • Introduction to the Physical Community • part of a home visitation course • Narrated van tour of West Philadelphia • Resident and fellow presentations in community sites

31. Faculty and Preceptor Education • One or two orientation sessions per year • Materials prepared with key readings and discussion questions for small groups • Debriefings after small group sessions

32. Evaluation • Students: one or two page description of an experience with presentation to peers in a small group • Focus groups of trainees • Critique of presentations and sessions: value, lessons learned

33. References and Materials • Full Curricula • UCSF: Culture and communication in health care, a curriculum • TACCT: Tool for assessing cultural competence training : a project initially privately funded, now adopted by the AAMC

34. References and Materials • Monographs and articles • Doorway Thoughts-American Geriatrics Society • Ham and Sloan: Cased Based Primary Care Geriatrics, chapters on Ethnic and Cultural Aspects of Geriatrics (4th and 5th editions). Jerry Johnson

35. Other Resources for Teaching • Stanford: stanford.edu/group/ethnoger • HRSA website: cultural and linguistic competence education: www.hrsa.gov/culturalcompetence/curriculumguide • The California Endowment website • Kaiser Foundation website • Manager’s electronic resource center (ERC) a cultural competence quiz produced by Management Sciences for Health

36. Summary • Cultural differences are common and germane. • The process of inquiry, rather than knowing a set of facts about a group, is fundamental. • Knowledge of critical domains can direct the interaction. • Several mnemonics are available. • Discussions and interactive exercises work. • Extensive resources on cross cultural care are available. • Culture matters